Gallstones

Question 1

Gallstone contents

Answer 1

• Phospholipids
• Bile pigments (broken down Hb) - associated with haemolysis - sickle cell anaemia
• Cholesterol

Question 2

Risk factors for gallstones (5Fs)

Answer 2

• Female
• Fat
• Fertile - OCP, pregnancy
• Forty +
• FHx
• Loss of terminal ileum (↓ bile salts)

Question 3

Complications of gallstones in the gall bladder

Answer 3

• Biliary Colic
• Acute cholecystitis ± empyema
• Chronic cholecytsitis
• Mucocele
• Carcinoma
• Mirizzi’s syndrome
• Fistula

Question 4

Mirizzi’s syndrome

Answer 4

Common hepatic duct obstruction caused by extrinsic compression from an impacted stone in the cystic duct or infundibulum of the gallbladder

Ix - MRCP
Mx- laparoscopic cholecystectomy.

Question 5

Biliary colic

Answer 5

Gallbladder spasm against a stone impacted in the neck of the gallbladder – Hartmann’s Pouch

Question 6

Presentation of gallstones

Answer 6

Biliary colic

• sudden dull RUQ pain radiating to back (scapular region)
• Associated with sweating, pallor, n/v
• Aggravated by fatty food and last <6h
• o/e may be tenderness in right hypochondrium
• ± jaundice if stones passes in to CBD

Question 7

Acute cholecystitis sign

Answer 7

Murphy’s sign +ve

• when palpating RUQ, painful when inhaling
• -ve on left

Question 8

Investigations for gallstones

Answer 8

• Bloods: FBC, U+E, amylase, LFTs, G+S, clotting, CRP
• Urine: bilirubin, urobilinogen, Hb
• Imaging
• AXR: 10% of gallstones are radio-opaque
• Erect CXR: perforation
• Transabdo USS (first line)

• If diagnosis uncertain after USS - HIDA cholescintigraphy: shows failure of GB filling
(requires functioning liver)

• If dilated ducts seen on USS → MRCP (gold standard)

Question 9

Treatment of gallstones

Answer 9

• Conservative

• Low fat diet, exercise
• Monitor LFTs: passage of stone spontanously
• Give vitamins ADEK
• Analgesia - morphine
• Cholestyramine - bile acid sequestrant preventing reabsorption
• Rehydrate

Surgery:
If no resolution, worsening LFTs or cholangitis:
- ERCP with sphincterotomy and stone extraction

Offered within 6 weeks of first presentation:
- Laparoscopic cholecystectomy

Question 10

Acute cholecystitis

Answer 10

• Stone impaction in Hartmann’s pouch or cystic duct

* chemical and/or bacterial inflammation

Question 11

Sequelae of acute cholecystitis

Answer 11

• Resolution ± recurrence
• Gangrene and rarely perforation
• Chronic cholecystitis
• Empyema

Question 12

Presentation of acute cholecystitis

Answer 12

• Severe RUQ pain
- Continuous
- Radiates to right scapula and epigastrium
• Fever
• Vomiting

Examination:
• Local peritonism in RUQ
• Tachycardia with shallow breathing
• ± jaundice
• Murphy’s sign

Question 13

Investigations for acute cholecystitis

Answer 13

•Bloods

• FBC: ↑ WCC
• U+E: dehydration from vomiting
• Amylase, LFTs, G+S, clotting, CRP
• Urine - bilirubin, urobilinogen
• Imaging
• AXR: gallstone, porcelain gallbladder
• Erect CXR: perforation
• USS - 1st line
• If the diagnosis is uncertain after USS - HIDA cholescintigraphy which shows failure of GB filling (requires functioning liver)
• MRCP if dilated ducts seen on USS (gold standard)

Question 14

Management of acute cholecystitis

Answer 14

Conservative:

• NBM
• Fluid resuscitation
• Analgesia: paracetamol, diclofenac, codeine

Medication:
- Abx: cefuroxime and metronidazole

Surgical

• Elective laparoscopic cholecystectomy surgery - within 1 week
• <72h ideal
• percutaneous cholecystostomy - if not fit for surgery and not responding to abx

Question 15

Chronic Cholecystitis

Answer 15

Symptoms: Flatulent Dyspepsia
• Vague upper abdominal discomfort
• Distension, bloating
• Nausea
• Flatulence, burping
• Symptoms exacerbated by fatty foods

Question 16

Investigations for Chronic Cholecystitis

Answer 16

• AXR: porcelain gallbladder
• USS: stones, fibrotic, shrunken gallbladder
• MRCP

Question 17

Mx of chronic cholecystitis

Answer 17

Mx
• Medical
- Bile salts (not very effective)

• Surgical

• Elective cholecystectomy
• ERCP first if US shows dilated ducts and stones

Question 18

Mucocele

Answer 18

Neck of gallbladder blocked by stone but contents remains sterile
• Can be very large → palpable mass
• May become infected → empyema

Question 19

Gallstone ileus

Answer 19

Stone impacts at the terminal ileum causing small bowel obstruction

Question 20

Rigler’s Triad

Answer 20

Pneumobiliia
Small bowel obstruction
Gallstone in RLQ

Question 21

Bouveret’s syndrome

Answer 21

Obstruction of proximal duodenum by a gall- stone in the gallbladder causing duodenal obstruction

Question 22

Ascending Cholangitis

Answer 22

• Obstruction of common biliary duct with infection
• Charcot’s triad:
• fever/rigors
• RUQ pain
• jaundice
• Reynolds pentad: Charcot’s triad + shock + confusion
• Mx
• urgent drainage if sepsis
• abx - Cef and met
• 1st: ERCP
• 2nd: Open or lap stone removal

Question 23

Pigment stones

Answer 23

Commonly seen in those with known haemolytic anaemia

Question 24

USS findings

Answer 24

• Stones: acoustic shadow
• Dilated ducts (>6mm)
• Inflamed GB: wall oedema

Question 25

Gallbladder Empyema

Answer 25

Gallbladder becomes filled with pus - can lead to sepsis and cause RUQ pain and fever

Ix - USS
Mx - laparoscopic cholecystectomy

Question 26

Cholecysto-duodenal fistula

Answer 26

Fistula between gall bladder and small bowel

Question 27

Causes of cholangitis

Answer 27

Gallstones
ERCP - iatrogenic
Cholangiocarcinoma

Rare:
Pancreatitis
PSC

Question 28

Common organisms in cholangitis

Answer 28

Escherichia Coli - most common
Klebsiella
Enterococcus (15%)

Question 29

Investigations for ascending cholangitis

Answer 29

Abdo exam
Routine bloods - leucocytosis + raised ALP

Blood cultures

USS - 1st line
MRCP - gold standard

Question 30

Mx of ascending cholangitis

Answer 30

1st line: ERCP

2nd line: PTC - percutaneous transhepatic cholangiography